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NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Decreased cardiac STO: 1. Assess vital signs. 1. Baseline data. Decreased renal and Goal partially met the
Parang hinahabol ko output related to Administer medication as liver function may lead to rapid patients pulse rate
yung pag hinga ko at reduced myocardial After 8 hours of nursing ordered and monitor intake and development of toxicity. decrease from 134 bpm
parati akong pagod contractility. intervention, the patient will output, and observe adverse to 110 bpm
kahit wala akong be able to maintain reaction. 2. Patients with silent myocardial
ginagawa as respiratory status within infarction frequently develop
verbalized by the established parameters. 2. Monitor for dyspnea dyspnea related to left-sided heart
patient. or breathlessness every 2 to failure.
LTO: 4hours, and report changes
Objective from baseline. 3. Dizziness, confusion, light-
Cold and clammy Not experience tachypnea, headedness, and restlessness may
skin on both feet. restlessness, anxiety, dyspnea, 3. Monitor mental status every 2 indicate cerebral blood flow
Increased confusion, nausea, fatigue, to 4hours and report deviations caused by slow carotid sinus reflex.
capillary refill or weakness. from baseline.
time (4-5 secs) 4. To increase oxygenation of
Fatigue 4. Administer oxygen to the brain and heart.
the patient as prescribed by
Body weakness
the physician. 5. To ease dyspnea, decrease oxygen
demand on myocardium,
Vital Signs: 5. Make sure that the patient gets and prevent
Temp:36.8 C adequate rest and doesnt exceed hydrostatic pneumonia
RR: 32 cpm her activity tolerance level.
PR: 110 bpm 6. To avoid Valsalvas maneuver
BP: 110/100 mmHg 6. Encourage patient to during defecation, which can increase
increase fluid intake and dietary heart rate and blood pressure.
fiber and to take natural stool
softeners.